Developing a Learning Community Amongst Residencies: The Integrative Medicine in Residency Project

Presenters Rita Benn, Ph.D. Mary Guerrera, M.D. Ben Kligler, M.D. Patricia Lebensohn, M.D. Victoria Maizes, M.D. Victor Sierpina, M.D. Selma Sroka, M.D.

IMR Faculty October 2007

Objectives Describe the steps in developing new competency based curriculum in integrative medicine for a diverse group of residencies Identify curricular core components Identify evaluation methodology Discuss challenges and opportunities

Questions for Participants What does Integrative Medicine add to Family Medicine? Modified needs assessment

What is the Integrative Medicine in Residency (IMR) Project? "Integrative Medicine in Residency (IMR) is a 250-hour curriculum development project of the University of Arizona Center for Integrative Medicine that will create and deliver competency based online integrative medical training to residents. IMR is initially being piloted in eight family medicine residencies with the goal of expanding to primary care and subspecialty training programs throughout the US and abroad."

Integrative Medicine “…healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle..… emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.”

Why graduate medical education? Undergraduate medical education curriculum is full. Early experiences in residency can have a negative effect on residents’ well-being. This can affect their ability to be: – compassionate with their patients – satisfied with their career choice

Why Family Medicine? Fundamentally a primary care specialty Bio-psycho-social model for patient care Applicants’ interest in integrative medicine Future of family medicine mandate is consistent with the goals of the IMR curriculum

IMR Goals Develop an online, competency based curriculum in integrative medicine tailored for family medicine residencies Design a set of competency based assessment tools Pilot the implementation of IMR curriculum and assessment process in 8 Family Medicine residencies

IMR Goals (cont.) Understand impact of IMR curriculum on residents and faculty Market and disseminate IMR curriculum to other family medicine residencies Adapt the curriculum for other primary care specialties

IMR Pilot Project Locations University of Arizona University of Texas Medical Branch Hennepin County Carolinas Medical Center Beth Israel University of Connecticut Maine-Dartmouth Maine Medical Center

Curriculum: Unique Characteristics Competency based Web-based and on site small group activities Common curriculum for multiple residencies Capacity to create a community of learners beyond the individual residency programs Built-in evaluation

What do we mean by competency based? ACGME outcome project competency domains include:  Patient care  Medical knowledge  Interpersonal and communication skills  Professionalism  Practice-based learning and improvement  Systems-based practice Respond to an initial needs assessment Develop a comprehensive evaluation system

What do you see as the three biggest challenges? Program Directors: –Time –Faculty acceptance –Curriculum structure Faculty: - Time - Faculty non-expertise - Resident interest Residents: - Time - Faculty non-expertise - General acceptance - Environmental context

Curriculum Year 1 Integrative Medicine Foundations (1 hr) Wellness and Prevention through the lifecycle (20 hrs) Wellness and self-care for the resident (9-12 hrs)

Curriculum Content – Year 1 Introduction to Integrative Medicine Wellness and Prevention throughout the lifecycle –Conventional prevention services –Nutrition and Supplements –Physical activity –Sleep –Mind-Body medicine –Spirituality Wellness/Self-care for the resident

Curriculum Process – Year 1 Web-based content and resources Clinical integration –Seven “short” clinical cases – web-based –Two “long” clinical cases – on DVD for small group discussion Self-care and wellness assessment and experiences

Curriculum: Years 2 and 3 Chronic Illness –Diabetes Mellitus –HTN –Hyperlipidemia –Heart disease –Fibromyalgia –Osteoarthritis –Rheumatoid Arthritis –Irritable Bowel –Back pain Women’s Health Topics - Menopause - Infertility - Pregnancy - Depression - Osteoporosis

Curriculum: Years 2 and 3 Children and Adolescents: –ADD –Headaches –Allergies and Asthma Integrative medicine for acute care: –Ankle sprain –UTI –URI –Diarrhea Putting integrative medicine into practice after residency

IMR Evaluation Plan Multi-level Assessment Goals 1.Competency Outcomes 2.Program Outcomes 3.Curriculum Outcomes Multi-method Approach Quantitative and Qualitative Multiple Instruments Mix of standardized and customized tools Observations, surveys, tests, portfolio

Competency Measures Patient Care: Observational Checklist, Patient survey, Portfolio, ICIS Medical Knowledge: Unit Tests, Portfolio, ICIS Interpersonal Skills: Observational Checklist, Patient survey Professionalism: Portfolio, Self-Assessment Systems-Based: Portfolio, Practitioner Survey Practice-Based: Portfolio, Self-Assessment

Program Outcomes Resident recruitment Current faculty learning/interest in IMR Faculty/resident attitudes toward IM Faculty/resident sense of community Resident well-being, stress and self- care

Comparative Study Plan Overall Design: Pre- and post-study of IMR and four comparison sites Three assessment intervals of endpoints Key Question: How does IMR curriculum, in contrast to conventional FM residency affect resident recruitment, capacities for doctoring, and knowledge and attitudes toward IM? Endpoints: 1. Resident well-being and burn-out 2. Physician-Patient interaction 3. Attitudes and knowledge of CAM 4. Resident recruitment pool

Curriculum Process Resident use and impact on learning –Survey and Technology reports Satisfaction of site –Needs Assessment –Site-Based Faculty use Concerns, challenges and successes in implementation –Interviews, Focus groups

Major Challenges in IMR Evaluation Design Multiple components comprising each competency Reliability of assessment tools and processes Variability in site-based evaluation measures Adding measurement burden to sites Human subjects consent –faculty, residents, patients Satisfying research and education goals

Challenges Ambitious project with multiple ongoing tasks to be accomplished and tight deadlines Residencies will have to be creative and flexible to include IMR in their curriculum Maintaining involvement of all faculty in the development of the material Maintaining contact with other programs interested in becoming early adopters

Challenges for participating programs Leap of faith, sign in without seeing the curriculum How to fit the hours Faculty and staff time to perform tasks around then IMR curriculum Communicating amongst programs and with the University of Arizona CIM via or conference calls

Pilot program motivation to participate Residencies that had the Integrative Family Medicine program Faculty interest in integrative medicine Participation would improve the recruitment of desirable applicants Being part of a nationally and collaborative project

“… path-finding is modeling the courage to determine a course and humility and mutual respect to involve others in deciding what matters most.” From The 8th Habit. SR Covey.

Questions for Discussion What are the minimum core components in integrative medicine that realistically should be taught and evaluated at the residency level? What are the advantages and disadvantages to using a web- based delivery approach to teaching integrative medicine competencies? How might implementation of a web-based curriculum affect faculty teaching and resident learning? How do you feel a web-based IMR program would fit in your residency?

IMR Faculty October 2007

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